Mehdi Aloosh is a Public Health and Preventive Medicine resident (R1) at McMaster University and a graduate of medicine from Tehran University and master’s in surgical education from McGill University
Cal Robinson is a pediatric resident (R1) at McMaster University and completed medical school in the UK
International Medical Graduates (IMGs) that match to residency positions in Ontario are required to participate in the Pre-Residency Program (PRP) in order to begin their residency. We participated in the 2017 PRP program as trainees and benefited from the learning opportunities specific to practicing medicine in Canada that the program provided. However, the PRP program structure does not follow the fundamental principles of Competency-Based Medical Education (CBME). PRP re-design, incorporating a CBME model of outcome-based assessment with identification of residents requiring additional support would optimize resource allocation within the program and improve its effectiveness and financial sustainability in Ontario.
The PRP has two phases: PRP1 and PRP2. PRP1 and the initial phase of PRP2 are held at Touchstone Institute in Toronto. The remainder of PRP2 is composed of 6 weeks of clinical clerkship at ones matched institution. IMGs matched to all family medicine and Royal College specialties are required to successfully complete PRP1. Only IMGs matched to family medicine programs are required to complete PRP2, while specialty residents proceed directly to their in-training Assessment Verification Period (AVP).
PRP1 focuses largely on the communicator and professional CanMEDs roles. Educational activities address law and ethics, privacy, confidentiality, and challenging patient encounters. Other roles of physicians, such as health advocate and collaborator are also touched. In this phase, the residents receive training at Touchstone for two weeks. This training incorporates various teaching methods, including lectures, simulation scenarios, online modules on selected material, and low-fidelity simulators. Indeed, PRP1 provides a good opportunity for IMGs to reinforce communication skills and be exposed to contemporary issues relevant to the practice of medicine in Canada. Also, it is an invaluable opportunity to meet practitioners and other residents, building valuable connections within a new healthcare system. Another benefit of the program is mutual training for specialty and family medicine residents. This multidisciplinary approach encourages good communication, collaboration and shared responsibility for health advocacy between primary and secondary care providers.
PRP2 is designed for family medicine residents. The first phase of PRP2 focuses on training specific to the practice of family medicine in Canada and takes two weeks at Touchstone. Following this, residents spend six additional weeks of clerkship in core rotations of family medicine, obstetrics and gynecology, internal medicine, pediatrics, and emergency medicine, at their matched institutions. Overall, Royal College specialty residents spend 2 weeks in the PRP program whereas family medicine residents are required to complete 2 months, resulting in significant delays to the start of their residency and associated financial consequences.
From a medical education perspective, PRP could be improved in several ways. First, PRP is not competency-based. It is a time-based training program with prescribed learning objectives. It does not account for the substantial variability in prior training and competencies among incoming IMG residents. By addressing these differences with more robust competency-based evaluation, the PRP could identify and target areas where residents require additional education or support and allow residents to progress through the program on an outcome-based timeline.
In CBME, design and content of teaching are based on the level of the trainee in their education. Moreover, trainees have a substantial role in defining their own learning requirements. From personal experience in the PRP, many residents probably demonstrate competence at initial assessment in certain domains. Additional training in these domains is unlikely to be of significant benefit to these individuals. Conversely, other residents demonstrated areas where additional clinical or non-clinical training would have been beneficial, which could not be provided using the current time-based model. These observations are based on the fact that trainees enter the program with unique skills and experiences and have different learning styles and speed of progression. Therefore, tailoring PRP for each resident could improve the efficiency and minimize cost of the program, while enabling demonstration of required competency achievement among IMG residents. One potential solution would be the objective assessment of trainees at the start of PRP with educational activities assigned on the basis of competency achievement. This would further allow trainees to participate in objective-setting, to consolidate the program curriculum with their educational needs. This would change the PRP from a time- to outcome-based design and shorten the program for the majority of residents.
It has been proven that assessment not only drives learning but helps to learn. In PRP, residents solely receive formative feedback on their performance in simulated patient encounters. Moreover, there is no summative assessment of competencies or evaluation of trainee’s objectives. Incorporation of summative feedback to the PRP would allow for evaluation of the program’s intended learning outcomes. Instead, summative assessment for IMGs is deferred to the AVP, where monthly resident evaluations are required for progression into residency. The hidden curriculum suggests that professionalism is the most important factor involved in successful completion of this stage. However, educators believe that any education program should be as explicit as possible about learning goals to avoid trainee confusion and anxiety.
In addition, implementation of CBME could probably decrease the financial costs of the training program. This includes the cost for faculty, simulated patients, space, educational material and trainee stipends. Based on my calculations, the cost of stipends alone likely approximates $348,000, per year.
Moreover, there were 88 IMGs matched into family medicine residency programs in Ontario in 2017, according to R-1 match reports. (6) By expediting the process that prevents this cohort from starting clinical practice, these individuals may start practice sooner and meet necessary training competencies earlier, improving the delivery of patient care.
Finally, increasing the number of online modules would allow for delivery of more theoretical and knowledge-based educational content, and allow for assessment of this material. Online training would not only reduce expenses for the health system but also reduce expenses for participants. Online training could also be used in simulation scenarios. Online training has the capacity to be improved rapidly, based on trainees’ objective performance and their reflection. Moreover, the availability of online training could help future candidates achieve competencies prior to the main residency match. This consequently will lessen the cost of training in the future. Moreover, timely assessment of the online training will enhance learning and assures that the required competencies have been acquired.
In conclusion, PRP provides many learning opportunities for IMG residents; however, it lacks CBME specifications. Tailoring the program for the trainees, more rigorous assessment and availability of online training could enhance learning, while reducing costs.
Thanks Mehdi and Cal, great reflection on PRP. I am a family medicine resident who went through PRP as a CSA and I agree with Deepika’s comment about how the needs for the various types of IMGs differ. An additional suggestion to the organizers would be to coordinate with the programs, particularly with regards to PRP2, to minimize overlap with academic half days. I found that we received the same talks in PRP2 that we received during our academic half days with our non-IMG cohort. This made the additional 2 weeks spent in the classroom feel like a less than ideal use of time.
Thank you Mehdi and Cal for taking the initiative to start discussions on improving the PRP experience. I agree that it needs to be re-designed to incorporate a CBME approach. While doing this I would like to recommend that they take into consideration the diverse training, experiences, and background of an IMG. Compared to few years ago when IMGs were mainly recent immigrants new to Canada, in recent years a large number of IMGs are CSAs (Canadian Studied Abroad) who have lived and even worked in the Canadian system. The needs and training requirements of CSAs is thus very different than the training required for a recent immigrant IMG who probably has to deal with additional cultural and luggage barriers.